No Suprise Act & Good Faith Estimate
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act” which required practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care expenses to private pay patients as well as patients who are using out-of network benefits for payment of care. The GFE works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based upon client provided information known at the time the service is requested. The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and will be provided a new GFE should this occur.
Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers or health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal Health Care Program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling services to receive a GFE of expected charges. The PHSA and GFE do not apply to clients who are using insurance benefits
Practitioners are required to provide a GFE of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested service. This GFE must be provided within specified timeframes.
- If the service is scheduled at least 3 business days before the appointment date, the GFE must be provided no later than 1 business day after the date of appointment/service request.
- If the service is scheduled at least 10 business days before the appointment date, the GFE must be provided no later than 3 business days after the date of appointment/service request.
- IF the uninsured or private-pay patient request a GFE without scheduling services, the estimate must be provided no later than 3 business days after the date of request
What is Included in the GFE
The GFE requires that the following information be included.
- Provider’s Name, NPI#, and Tax ID
- Provider’s Phone Number
- Provider’s Email Address
- Provider’s Address & Address of Location Where Services Will Be Provided
- Client’s Full Name, Address, Telephone, and Email Address
- Client’s Contact Preference
- Preliminary Diagnosis
- Primary Diagnosis & Secondary Diagnosis & Codes
- Date of Scheduled Visits
- Date of The GFE
- Service Item
- Location Where Services Are Provided
- The Rate of the Service
- Expected Length of Treatment
- Total Expected Costs
This Good Faith Estimate shows the costs of items and services that are reasonable expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than the GFE, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25.00 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and to get a form to start the process, questions about your rights, go to www.cms.gov/nosurprises.